The present study reported the results of the routine use of IOE during LSG. No leak was detected during IOE, but 3 out of 352 patients (0.9%) were found to have gastric stenosis which was immediately relieved intraoperatively. No patients had clinical gastric stenosis or leak after LSG. Of note, all cases occurred within the first 30 cases of the surgeons starting to perform LSG suggesting that IOE can assist less experienced surgeons in LSG to prevent stenosis.
Gastric stenosis can be classified as mechanical stenosis or functional stenosis 22. Mechanical stenosis occurs when it is difficult for the endoscope or it is unable to pass through the sleeve, whereas functional stenosis occurs when the endoscope passes through the sleeve with a variable degree of rotation. Although both types of stenosis presented similarly, the diagnosis period was different, with a mean diagnosis period for the mechanical type 9.5 days after the procedure and 43.2 days for the functional type 22. Gastric stenosis after sleeve gastrectomy could be caused by ischemia, retraction by scarring, misalignment during stapling, prolonged operation time, or a short pylorus distance 23,24. In our study, the gastric stenosis resulted from tightly gastropexy stitch or reinforcement stitch and could be regarded as mechanical stenosis, which was resolved after removal of the stitch. However, if not treated, symptoms might occur soon after the operation.
Chang et al. reported that the incidence of gastric stenosis decreased from 2.1% (7/338) to 0% (0/489) after surgical standardization of LSG 8,25. As shown in the present study, the overall incidence of gastric stenosis detected by IOE was 0.9% (3/352). However, if the cases performed when surgeons were less experienced were excluded, no gastric stenosis occurred after LSG, indicating that care should be taken to avoid complications during this period. Although additional instruments and an experienced endoscopist are required, IOE is safe and can be used to detect complications during LSG. Nimeri et al. performed IOE during LSG and found 10 cases (3.2%) of gastric stenosis during the procedure. Stenosis resolved after removing over-sewing sutures and clinical stenosis after LSG was 0% 20. As shown in the present study, IOE can guide the surgeons to check the cause and location of stenosis with revision performed laparoscopically.
Leaks remain the most important complication causing significant morbidity and mortality after LSG 26. The surgeons made every effort to decrease the incidence of leaks, including omentopexy, staple-line reinforcement, oversewing suture, absorbable polymer membrane, or no reinforcement 27. The development of a leak after LSG might result from ischemia in the gastric wall next to the staple line, stenosis of the sleeve, or increased intraluminal pressure related to low compliance of the gastric tube 11,28. The role of IOE in preventing leaks has been reported in several studies. Jung et al. performed a propensity-matched analysis using the MBSAQIP database and reported no significant post-LSG leaks between patients who underwent an intraoperative leak test and those who did not (0.4% v.s. 0.3%, p = 0.05) 29. Nimeri et al. performed IOE during LSG and reported a leak rate of 0% in primary LSG 20. Similarly, we also detected no leaks during IOE and after the operation. It cannot be concluded suggested that IOE with a leak test did help prevent leaks after LSG, so further studies are needed to confirm this.
We reported the low percentage of stenosis and leak after LSG. Although IOE could help identify stenosis during LSG, and stenosis could be corrected during operation, the cost-effectiveness issues of IOE need to be assessed. In addition, because all stenosis occurred during the learning curve of less experienced surgeons, it is also important to evaluate whether more training with a full experienced bariatric surgeon can decrease this complication and replace IOE. Our study has several limitations. First, it was an observational study and did not include a comparative group that did not have IOE. We did not know whether the stenosis found in IOE will cause clinical symptoms if it was not relieved during LSG. Second, not all patients were followed up and it is possible that some may have had signs of gastric stenosis and sought other medical help. Although complete biochemical measurement and follow-up gastroscopy were available in only 101 patients (28.7%), all patients in the present study had at least one return visit after the operation. Symptoms of gastric stenosis often occur within 3 months post-procedure 25, but none of our cohort had symptoms of gastric stenosis.
In conclusion, IOE can help detect gastric stenosis during LSG, especially for surgeons less experienced in LSG. The stenosis could be corrected during the procedure, which might prevent clinical stenosis post operation. However, because no leak was detected by IOE or occurred after LSG in the present study, the use of IOE with a leak test to prevent leaks is not necessary.